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Jones, Lawrence If I'-'_) NEW YORK STATE DEPARTMENT OF HEALTH ... Vital Records Section Burial - Transit Permit Name First Middle Last Sex Lawrence H Jones Male Date of Death Age If Veteran of U.S.Armed Forces, F November 20, 2013 81 War or Dates NO 2 Place of Death Hospital, Institution or W City,Town,or Village Gloversville Street Address Fultin Center for Rehab G Manner of Death ©Natural Cause El Accident El Homicide Ei Suicide IDUndetermined Ei Pending W Circumstances Investigation Medical Certifier Name Title W ,VFL,EIUt L. h��l,4-%5-Ent RP4 - c. Q Address D�� 0®� CvV 7 t!'oca nI�5. k©tf IE /,707 ‘/Q u6-R,s iii `le /�ew 3. Death Certificate Filed District Number /7 ry Register Number City,Town or Village Gloversville �! 9 ❑Burial Date Cemetery or Crematory November 25, 2013 Pineview Crematorium El Entombment Address 0 Cremation Guaker Road Queensbury, NY 12804 i Date Place Removed 4 0 Removal and/or Held - and/or Address F Hold 11 Date Point of 0 El Transportation Shipment d by Common Destination Carrier Date Cemetery Address o Disinterment Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Jillson Funeral Home, Inc. 00885 Address I. 46 Williams Street, Whitehall, New York 12887 2 Name of Funeral Firm Making Disposition or to Whom I, Remains are Shipped,If Other than Above W Address 0. Permission is hereby granted to dispose of the human remains bed above,�ss i icated. Date Issued /// 40/3 Registrar of Vital Statistics �/ //�� ;;(( / gnature) 2 bistrict Number 52/ Place jA/,[.3,.` 9th..ze//20/L I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: z W Date of Disposition 11/25/2013 Place of Disposition Pineview Crematorium 2 (address) W In 0 (section) t number) K (grave number) aName of Sexton or Person in Ch rge of Prem' es ,� 3f„,ri z (pleae print) W Signature 1L Title is p itt-h'c. (over) DOH-1555 (02/2004)